Avert misidentification and prevent wrong patient procedures

Patient Id2

Headlines were made after a kidney was removed from the wrong patient during surgery at St. Vincent Hospital in Worcester this past July. Wrong patient procedures like this one are considered “never events,” according to the Agency for Healthcare Research and Quality: an error that must not occur and indicates serious underlying safety problems. 

Misidentification errors resulting in serious patient harm remain an all-too-common occurrence in Massachusetts and nationwide. Indeed, Massachusetts health-care facilities have reported at least seven cases of wrong patient surgery since the start of 2015. See "Cases in point" below.

These cases offer lessons in how even seemingly minor administrative errors can lead to catastrophic harm in the absence of strong systems to prevent patient misidentification and to catch mistakes before they cause injury. “[Identification errors] occur during multiple procedures and processes and can involve nearly anyone on the patient’s health care team,” an August report by the ECRI Institute noted. “As a result, no single strategy can prevent these events; instead, organizations must adopt a multipronged approach to prevent wrong-patient mistakes.”

Two patients with the same name

In the St. Vincent case, two patients with the same first and last names — but different birth dates — had coincidentally received Computerized Tomography (CT) scans at another hospital on the same day several weeks before the mistaken surgery. According to a review by the Department of Public Health’s Division of Health Care Facility Licensure and Certification on behalf of the Centers for Medicare and Medicaid Services, the patient’s “admission and plan for surgery to remove (a) tumorous kidney was based on the other patient’s CT scan results, in error.” 

St. Vincent has been given until mid-December to correct deficiencies in patient identification practices or risk losing its eligibility for reimbursement by CMS. The hospital’s CEO Steven MacLauchlan said, “We are on track to meet — and I expect, exceed — all of the expectations and deadlines in the plan we put forth in collaboration with state and federal officials.”

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1. In April 2015, a patient received an erroneous order for a central catheter. The physician had intended to write the order for a different patient under the care of a different physician. After confirming the order, a nurse obtained consent from the patient using a telephone interpreter service at the bedside. While the nurse was placing the line, the error was recognized by another care team member. The line had already been inserted and was removed.

2. In July 2015, a patient at an eye surgery center was given a laser procedure intended for a different patient.

3. In August 2015, hospital Patient A received cancer radiation treatment intended for hospital Patient B. A radiation therapist went to the waiting room to escort Patient B to the treatment room just as Patient A was arriving. The therapist did not ask Patient A for identification and treated her assuming she was Patient B. The error was discovered only after the therapist accessed the plan for the next scheduled patient, Patient A, and realized that she was the patient who had just been treated.

4. In March 2016, an endoscopy was mistakenly performed on an elderly patient who had been admitted to a hospital’s telemetry unit for evaluation and treatment of atrial fibrillation even though no one on the patient’s care team had ordered a GI consult or a diagnostic procedure.

5. In April 2016, a nurse placed a midline in the wrong patient. The patient had a history of Alzheimer’s Disease. When the nurse entered the room, the nurse called out the correct patient’s name, and the wrong patient responded affirmatively. The nurse did not double check the wrist band, and put the line in the incorrect patient.

6. In April 2016, two patients with the same name and similar dates of birth, both of whom originated from the same foreign country, were being treated within the same hospital system. A liver biopsy intended for one of the patients was performed on the other patient.

Strategies for reducing mistakes

The ECRI Institute report offers a number of evidence-based recommendations for preventing adverse events associated with patient misidentification:

  • Always use two patient identifiers to confirm the person’s identity at the beginning of each encounter. Patient identifiers can include the patient’s name, date of birth, unique hospital ID number, Social Security number or photo. Staff should not use bed locations, room numbers, or diagnoses to identify patients.
  • Avoid “leading” the patient when asking for identifiers. An open-ended statement like “Please tell me your name” is better than asking “Are you Mrs. Jones?” to prevent patients from accidentally confirming an incorrect name or other identifier.
  • Put in place protocols for patients in the same unit or department with similar names, including alternate identifiers, and avoid putting patients with similar names in the same room.
  • Confirm patients’ identity before labeling specimen containers. Staff should not label containers until the specimen has been collected. After double-checking identification information, attach the label to the container in the patient’s presence. Carry multiple preprinted specimen labels for only one patient at a time so the wrong ones will not get used.
  • Note any patient-specific identifiers during handoff conversations. Shift changes are common times for mistakes because of incomplete handoff conversations. Institute a process in which staff relays information about the identifiers used for each patient, and have staff confirm all patients’ identities at the start of their shifts.
  • Engage patients in the identification process. Before getting basic demographic information from each patient, ask if there are any accommodations they need to better communicate with providers (e.g., translators), and find resources to meet those needs. And educate patients about the importance of repeated questions about their names and dates of birth to avoid identification errors.

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Email us your feedback and comments: patientsafetybeat@state.ma.us